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Unformatted text preview: ume repletion: decrease tubular light chain • • • concentration, decrease tubular NaCl concentration Increase urine flow: decrease light chain precipitation Alkalinize urine: raise urine pH above isoelectric point to decrease affinity toward anionic Tamm­ Horsfall proteins (controversial) Chemotherapy to decrease immunoglobulin production Plasmapheresis to remove Plasmapheresis to remove circulating free light chains? • Many studies are small, non­randomized, retrospective, are heterogeneous… • 3 prospective, randomized trials: 2 favor plasmapheresis, while most recent one casts doubt on its use Plasmapheresis? Plasmapheresis? • Zucchelli 1988: 29 patients (24/83% req dialysis), 59% biopsied, Cr > 5mg/dl not responsive to hydration, 80% treated previously w/ cytotoxic drugs, all given methylprednisolone & cyclophosphamide & randomized to plasmapheresis w/ prn HD vs. prn PD; 13/15 v. 2/14 w/ renal improvement; also survival benefit Plasmapheresis? Plasmapheresis? • Johnson 1990: 21 patients (...
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